• Title/Summary/Keyword: Medication error

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Canonical Correlation between Drug Dosage Calculation Error Prevention Competence of Nurses and Medication Safety Organizational Climate (약물계산 오류예방을 위한 간호사의 역량과 투약안전과 관련된 병원조직풍토간의 정준상관관계)

  • Kim, Myoung Soo
    • Korean Journal of Adult Nursing
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    • v.24 no.6
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    • pp.569-579
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    • 2012
  • Purpose: The purpose of this study was to investigate the relationship between drug dosage calculation error prevention competence and medication safety organizational climate. Methods: We surveyed 207 nurses from 15 hospitals. An assessment survey was designed to assess the medication safety organizational climate which consisted of four subcategories including medication safety cultures, medication safety initiatives, medication error communication, and medication error management competence. The drug dosage calculation error prevention competence contains two subcategories; Dosage calculation habits and ability. The data were collected from July to August 2011. Descriptive statistics, t-test, ANOVA, partial Pearson correlation coefficient, canonical correlation were used. Results: Organizational climate was related to dosage calculation error prevention competence with two significant canonical variables. The first canonical correlation coefficient was .53 (Wilks' ${\lambda}$=0.71, df=8, p<.001) and that of the second was .21 (Wilks' ${\lambda}$=0.96, df=3, p=.027). The first variate indicated higher perception of medication safety cultures, safety initiatives, error communication and error management competence were related to better dosage calculation habits. The second variate showed higher perception of medication safety cultures and lower medication error management competence were related to higher calculation ability. Conclusion: Continuous supporting strategies for medication safety organizational climate should be implemented to improve drug dosage calculation habits.

Role of Transformational-leadership in the Relationship between Medication Error Management Climate and Error Reporting Intention of Nurse (간호사가 인지한 투약오류관리풍토와 오류보고의도의 관계에서 변혁적 리더십의 역할)

  • Kim, Myoung Soo
    • Korean Journal of Adult Nursing
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    • v.25 no.6
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    • pp.633-643
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    • 2013
  • Purpose: The objective of this study was to identify the moderating and mediating effects of transformational-leadership in the relationship between medication error management climate and error reporting intention. Methods: Participants in this study were 118 nurses from 11 hospitals in Korea. The scales of medication error management climate, transformational-leadership and error reporting intention of nurses were used in this study. Descriptive statistics, t-test, ANOVA, partial Pearson correlation coefficient, and stepwise multiple regression were used for data analysis. Results: Higher transformational leadership group members had higher error management climate (t=3.88~4.64, p<.001) and higher intention to error reporting (t=2.49, p=.014). There were significant positive correlations between subcategories of medication error management climate and transformational leadership (r=.37~.51, p<.001). But error reporting intention was related to the transformational leadership (r=.28 p=.002), two subcategories such as 'learn from error' (r=.26, p=.004) and 'medication error competence' (r=.25, p=.008) of medication error management climate. Transformational-leadership was a moderator and a mediator between medication error management climate and error reporting intention. Conclusion: Based on the results of this study, transformational-leadership promotion training program to construct medication error management climate and to improve error reporting intention should be needed.

Types of Medication Error to Be Used in Korea (의약품 사용 오류)

  • Kim, Hyungtae;Choi, Hye Duck;Kim, Siin;Han, Sola;Lee, Iyn-Hyang;Suh, Hae Sun
    • The Journal of Health Technology Assessment
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    • v.5 no.1
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    • pp.31-41
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    • 2017
  • Objectives: To explore prevalently used types of medication error and the types of medication error which would be appropriate to be used in Korea. Methods: In depth literature review was performed to explore the mostly used types of medication error in the United States, Canada, Europe, Australia, and Japan. We intended to examine experts' view on the suitability of the types of medication error to be used in Korea. The types of medicati0on error were classified by activity criteria, severity criteria, process criteria, and responsible person criteria based on literature reviews. Results: According to the result of literature review, activity criteria was the most commonly used type of medication error. Ten experts in the area of patient-safety and medication error responded and the top two types of medication error which were appropriate and suitable to be used in Korea were severity criteria and activity criteria. Conclusion: Severity criteria and activity criteria could be recommended to be used as the standard types of medication error in Korea although there are other types of criteria such as process criteria and responsible person criteria.

Correlation among the Medication Error Risk of High-alert Medication, Attitudes to Single Checking Medication, and Medication Safety Activities of Nurses in the Intensive Care Unit (중환자실 간호사의 고위험약물에 대한 투약오류 위험과 약물단독확인 태도, 투약안전간호활동 간의 상관성)

  • Kim, Myoung Soo;Jung, Hyun Kyeong
    • Journal of Korean Critical Care Nursing
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    • v.8 no.1
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    • pp.1-10
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    • 2015
  • This study was conducted to examine the relationship among the error risk of high-alert medication, attitudes to single-person checking of medication, and medication safety activities. The participants were 60 nurses working in the intensive care unit. Data were analyzed using descriptive analysis, t-test, analysis of variance, and Pearson's correlation coefficient. The mean scores of the knowledge and certainty of high-alert medication were $0.71{\pm}0.11$ and $2.74{\pm}0.59$, respectively. The mean score of the error risk of high-alert medication was $1.63{\pm}0.24$ and that of attitudes to single checking medication was $3.32{\pm}0.49$. The error risk of high-alert medication had a positive correlation with nurses' attitudes to single checking medication (r = .258, p = .047), which is correlated with the scores for certainty of knowledge (r = .284, p = .028). Based on the results of this study, continuing education for high-alert medication and the development of an accurate protocol for single checking medication are needed to improve the stability of high-alert medication.

Medication Error Management Climate and Perception for System Use according to Construction of Medication Error Prevention System (환자안전 관리자가 인식한 투약오류예방 시스템 구축실태에 따른 투약오류관리풍토 및 활용인식)

  • Kim, Myoung-Soo
    • Journal of Korean Academy of Nursing
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    • v.42 no.4
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    • pp.568-578
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    • 2012
  • Purpose: The purpose of this cross-sectional study was to examine current status of IT-based medication error prevention system construction and the relationships among system construction, medication error management climate and perception for system use. Methods: The participants were 124 patient safety chief managers working for 124 hospitals with over 300 beds in Korea. The characteristics of the participants, construction status and perception of systems (electric pharmacopoeia, electric drug dosage calculation system, computer-based patient safety reporting and bar-code system) and medication error management climate were measured in this study. The data were collected between June and August 2011. Descriptive statistics, partial Pearson correlation and MANCOVA were used for data analysis. Results: Electric pharmacopoeia were constructed in 67.7% of participating hospitals, computer-based patient safety reporting systems were constructed in 50.8%, electric drug dosage calculation systems were in use in 32.3%. Bar-code systems showed up the lowest construction rate at 16.1% of Korean hospitals. Higher rates of construction of IT-based medication error prevention systems resulted in greater safety and a more positive error management climate prevailed. Conclusion: The supportive strategies for improving perception for use of IT-based systems would add to system construction, and positive error management climate would be more easily promoted.

A Study on the Types and Causes of Medication Errors and Related Drugs - by Analyzing AJNs Medication Error 73 Cases - (임상에서의 투약오류원인과 관련 의약품 분석 - AJN에 기고된 Medication Error 기사의 73사례를 중심으로 -)

  • Cho Won Sun
    • Journal of Korean Public Health Nursing
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    • v.16 no.1
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    • pp.176-189
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    • 2002
  • The purpose of this study were to illustrate the various medication error types and causes and identified to related drugs to provide basic data for preventing nurses' medication error by analysing 73 cases of AJN 'medication Error' column(1993, Oct -2000, Nov). Nurses' types of medication error were classified into 7 types. The most frequent error types are wrong medication$(21.9\%)$ and the wrong dose$(21.9\%)$ together. The others are wrong $time(4.1\%)$, $omission(2.7\%)$, mechanical $error(2.7\%)$, incorrect IV $rate(1.4\%)$. wrong route $administration(1.4\%)$ in order. Nurses' causes of medication error were 9 kinds. The most frequent type is confusing between similar drug shape, color, size, name, injection devices and patient's $name(43.9\%)$ and the others are lack of knowledge about $drugs(26.8\%),\; slips(7.3\%),\; miscalculating\;dose(4.9\%)$, incorrect adjusts $devices(4.9\%)$, difficulty to read or illegible decimal $point(4.9\%),$ $abbreviation(2.4\%)$, fatigue with $overwork(2.4\%)$ and no communication with $patient(2.4\%)$ in order. Related drugs with medication error are as follows. - dose unit(IU. minims. mcg/min. mEq) : Heparin. insulin. synthetic calcitonin, some enzymes and hormones, vitamins, some antibiotics, tuberculin injection. MgSO4 injection. nitroglycerin - similar size, color and shape drug : $0.9\%$ N/S and acetic acid $0.25\%$ for irrigation. premixed 2mg lidocaine sol. and $0.9\%$ N/S, gentamycin 20mg/2mL for children and 80mg/2mL for adult, dextroamphetamine 5mg and 10mg capsule. sedatives chloral hydrate 250mg/5mL and 500mg/5mL - similar name :Aredia(pamidronate disodium) and Adriamycin(doxorubicin), Lamictal (lamotrigine) and Lamisil 250mg. Elderpryl and enalapril, cefotaxime and cefoxitin, carboplatin and cisplatin, sumatriptan and zolmitriptan, Celebrex and Celexa, Humulin and Humalog, Percodan and Percocet, Diabeta and Diabinese, Epivir and Retrovir, Xanax(alprazolam) and Zantac(ranitidine) - decimal point : low molecular weight warfarin, methotrexate - unfamiliar drug uses of familiar drug ; methotrexate. droperidol, imipramine, propranolol - number of drug name(misleading chemical name) : 6-thioguanine, 6-mercaptopurine, 5-fluorouracil - type of administration route : Oxycodone(OxyContin). - administration time : acarbose(Precose). - injection way (Z-track method): hydroxyzine - epidural cathether : LMWHs(enoxaparin, dalteparin), - ADD Vantage self contained delivery system : ceftriaxone(Rocephin)

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Critical Thinking Disposition, Medication Error Risk Level of High-alert Medication and Medication Safety Competency among Intensive Care Unit Nurses (중환자실 간호사의 비판적 사고성향, 고위험약물 투약오류 위험수준 및 투약안전역량)

  • Lee, Yoon Hee;Lee, Youngjin;Ahn, Jeong-Ah;Kim, Hee Jun
    • Journal of Korean Critical Care Nursing
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    • v.15 no.2
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    • pp.1-13
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    • 2022
  • Purpose : The study aimed to identify relationship among intensive care unit (ICU) nurses' critical thinking disposition, medication error risk level of high-alert medication, and medication safety competency, as well as the factors affecting medication safety competency. Methods : The participants were 266 ICU nurses of one higher-tier general hospital and one general hospital in Province. The data were collected using structured self-administered questionnaire from August 10 to August 31, 2021. Measurements included the critical thinking disposition questionnaire, nurses's knowledge of high-alert medication questionnaire, the medication safety competency scale. Data were analyzed using hierarchical multiple regressions using SPSS/WIN 28.0. Results : In the multiple regression analysis, the medication safety competence has a statistically significant correlation with the working department, the critical thinking disposition, and medication error risk level of high-alert medication. Conclusion : Based on the results of this study, it is suggested to develop and apply an educational strategy that can strengthen the knowledge and skills of critical thinking disposition and medication error risk level of high-alert medication to improve the ICU nurse's medication safety competency.

Canonical correlation between organizational characteristics and barrier to medication error reporting of nurses (간호사가 인식한 조직의 특성과 투약오류보고장애요인간의 정준상관관계)

  • Kim, Min-Jeong;Kim, Myoung Soo
    • Journal of the Korea Academia-Industrial cooperation Society
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    • v.15 no.2
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    • pp.979-988
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    • 2014
  • Purpose: The purpose of this study was to examine the relationship between nurse's perception of organizational characteristics including safety climate and work environment and barrier to medication error reporting. Methods: We surveyed 334 nurses from 7 hospitals. An assessment survey was consisted of modified safety climate scale, practice environment scale and barrier to medication error reporting. The data were collected from September 2012. Descriptive statistics, Pearson correlation coefficient, canonical correlation were used. Results: Organizational characteristics were related to barrier to medication error reporting with three significant canonical variables. The first canonical correlation coefficient was .50(Wilks' ${\lambda}$=0.61, df=32, p<.001), that of the second was .35(Wilks' ${\lambda}$=0.81, df=21, p<.001) and that of the third was .22(Wilks' ${\lambda}$=0.93, df=12, p=.018). The first variate indicated higher perception of safety climate variables and work environment variables were related lower barrier to medication error reporting variables except fear for error reporting. The second variate showed higher perception of 'safety climate between healthcare provider' and higher 'nurse participation in hospital affairs' and 'staffing and resource adequacy' were related to lower 'fear' and 'administrative response' in barrier to medication error reporting variables. Conclusion: Strategies for barrier to medication error reporting and improvement of organizational characteristics including safety climate and work environment should be implemented.

Perception and Experience of Medication Errors in Nurses with tess than One Year Job Experience (신규 간호사의 투약오류 인지 및 경험에 대한 조사 연구)

  • Oh, Choon-Ae;Yoon, Hae-Sang
    • Journal of Korean Academy of Fundamentals of Nursing
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    • v.14 no.1
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    • pp.6-17
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    • 2007
  • Purpose: This study was carried out to investigate perception and experience of medication errors by nurses. Method: Data collection through a survey was performed using structured questionnaires over the period of September 1 to October 15, 2004. Questionnaire were delivered to 222 nurses from 15 hospitals; thereafter, 205 questionnaires were responded (i.e., 92% response rate). The subject in the study was a nurse who had been working in the hospital for less than one year. Results: The average perception rate was 87.5%. The perception rates of subjects in medication errors from four areas are 62% in wrong dosage form for drug administration, 61.5% in air into an IV set, 63% in crystals in an IV lines, and 83.5% in wrong time. The experience rates of subjects in medication errors from four areas are 85.5% in wrong time, 39.5% in wrong injection site, 34.5% in omission error, and 28% in wrong patient. Conclusion: The average perception rate and experience rates of medication errors were 87.5% and 23.5%, respectively. Education about the Five right in medication and knowledges about drugs would improve the perception of medication errors of nurses whose work experience is less than one year, and prevent them from medication errors.

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Medication Errors in Chemotherapy Preparation and Administration: a Survey Conducted among Oncology Nurses in Turkey

  • Ulas, Arife;Silay, Kamile;Akinci, Sema;Dede, Didem Sener;Akinci, Muhammed Bulent;Sendur, Mehmet Ali Nahit;Cubukcu, Erdem;Coskun, Hasan Senol;Degirmenci, Mustafa;Utkan, Gungor;Ozdemir, Nuriye;Isikdogan, Abdurrahman;Buyukcelik, Abdullah;Inanc, Mevlude;Bilici, Ahmet;Odabasi, Hatice;Cihan, Sener;Avci, Nilufer;Yalcin, Bulent
    • Asian Pacific Journal of Cancer Prevention
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    • v.16 no.5
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    • pp.1699-1705
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    • 2015
  • Background: Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience. Materials and Methods: This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data. Results: Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%). Conclusions: Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures and establishing multistep control mechanisms.